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Toronto Notes 2019 Hand Plastic Surgery PL25 Hand Infections
Principles
• traumaismostcommoncause
• 5cardinalsigns:rubor(red),calor(hot),tumour(swollen),dolor(painful),andfunctiolaesa(lossof
function)
• 90%causedbyGram-positiveorganisms
• mostcommonorganisms(inorder)–S.aureus,S.viridans,GroupAStreptococcus,S.epidermidis,and
Bacteroides melaninogenicus (MRSA is becoming more common)
TYPES OF INFECTIONS
Deep Space Infections
• abscessformationindeepspacesofthehand,mostcommonlythenarormid-palmspace • uncommon,thereare9spacesinthehand
Felon
• definition:abscessinthepulpofafingertiporthumbthatoccursfollowingapuncturewoundintothe pad of the digit; may be associated with osteomyelitis (akin to compartment syndrome and can lead to skin necrosis)
• treatment:elevation,warmsoaks,cloxacillin500mgPOq6h(ifinearlystage);ifobviousabscessor pressure on the overlying skin or failure to resolve with conservative measures, then needs I&D, take cultures/gram stain and adjust antibiotics to culture results
Flexor Tendon Sheath Infection
• Staphylococcus>Streptococcus>Gram-negativerods
• definition:abscesswithintheflexortendonsheath(flexortenosynovitis),commonlycausedbya
penetrating injury and can lead to tendon necrosis and rupture if not treated; it is often suppurative;
however, there can be very little pus early on
• clinicalfeatures:Kanavel’s4cardinalsigns
1. point tenderness along flexor tendon sheath 2. severe pain on passive extension of digit
3. fusiform swelling of entire digit
4. flexed posture (increased comfort)
• treatment
■ non-suppurative: IV antibiotics, resting hand splint until infection resolves, aggressive hand therapy
after; I&D in OR
■ suppurative (produces pus): copious catheter irrigation and debridement of wound
Herpetic Whitlow
• HSV-1, HSV-2
• definition:painfulvesicle(s)aroundfingertiporthumb
■ often found in medical/dental personnel and children
• clinicalfeatures:canbeassociatedwithfever,malaiseandlymphadenopathy,prodromalphase
■ patient is infectious until lesion has completely healed
• treatment:diagnosedclinically,ifindoubtconfirmwithviralculture/PCRorTzancksmear,usually
self-limited, consider oral acyclovir in severe cases; I&D is contraindicated
Paronychia
• acute=Staphylococcus;chronic=Candida
• definition:infection(granulationtissue)ofsofttissuearoundfingernail(withintheparonychiumand/
or beneath eponychial fold)
• etiololgy
■ acute paronychia: a “hangnail”, artificial nails, and nail biting
■ chronic paronychia: prolonged exposure to moisture
• treatment
■ acute paronychia: warm compresses and oral antibiotics if caught early; if abscess present, drainage with blade (avoid hitting nail bed) and oral/IV antibiotics; if abscess extends to below nail plate, nail plate removal may be required
■ chronic paronychia: anti-fungals, eponychial marsupialization, nail plate removal may be required